Provider Demographics
NPI:1942516844
Name:MIND AND BRAIN CARE LLC
Entity Type:Organization
Organization Name:MIND AND BRAIN CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:239-768-6500
Mailing Address - Street 1:10175 6 MILE CYPRESS PKWY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-9663
Mailing Address - Country:US
Mailing Address - Phone:239-768-6500
Mailing Address - Fax:239-768-6421
Practice Address - Street 1:10175 6 MILE CYPRESS PKWY STE 3
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-6993
Practice Address - Country:US
Practice Address - Phone:239-768-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7375103G00000X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75725OtherBCBS
FL6022640OtherCIGNA
FL6022640OtherCIGNA